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11.7. RECOMMENDATION
11.7.1.1 Drug treatment is not indicated as the first-line treatment for all school-age
children and young people with ADHD. It should be reserved for those
with severe symptoms and impairment or for those with moderate levels of
impairment who have refused non-drug interventions, or whose symptoms
have not responded sufficiently to parent-training/education programmes
or group psychological treatment
35
.
35
This recommendation is also included as 10.18.2.1 in Chapter 10.
Combining and comparing psychological and pharmacological interventions
359
Summary of recommendations
360
12. SUMMARY OF RECOMMENDATIONS
12.1 PREREQUISITES OF TREATMENT AND CARE FOR ALL
PEOPLE WITH ADHD
12.1.1 Organisation and planning of services
12.1.1.1 Mental health trusts, and children’s trusts that provide mental health/child
development services, should form multidisciplinary specialist ADHD
teams and/or clinics for children and young people and separate teams
and/or clinics for adults. These teams and clinics should have expertise in
the diagnosis and management of ADHD, and should:
● provide diagnostic, treatment and consultation services for people with
ADHD who have complex needs, or where general psychiatric serv-
ices are in doubt about the diagnosis and/or management of ADHD
● put in place systems of communication and protocols for information
sharing among paediatric, child and adolescent, forensic, and adult
mental health services for people with ADHD, including arrangements
for transition between child and adult services
● produce local protocols for shared care arrangements with primary
care providers, and ensure that clear lines of communication between
primary and secondary care are maintained
● ensure age-appropriate psychological services are available for chil-
dren, young people and adults with ADHD, and for parents or carers.
The size and time commitment of these teams should depend on local
circumstances (for example, the size of the trust, the population covered
and the estimated referral rate for people with ADHD).
12.1.1.2 Every locality should develop a multi-agency group, with representatives
from multidisciplinary specialist ADHD teams, paediatrics, mental health
and learning disability trusts, forensic services, child and adolescent
mental health services (CAMHS), the Children and Young People’s
Directorate (CYPD) (including services for education and social services),
parent support groups and others with a significant local involvement in
ADHD services. The group should:
● oversee the implementation of this guideline
● start and coordinate local training initiatives, including the provision of
training and information for teachers about the characteristics of
ADHD and its basic behavioural management
● oversee the development and coordination of parent-training/education
programmes
● consider compiling a comprehensive directory of information and
services for ADHD including advice on how to contact relevant
services and assist in the development of specialist teams.
12.1.2 Information, consent, the law and support for people with ADHD
and their carers
12.1.2.1 Healthcare professionals should develop a trusting relationship with people
with ADHD and their families or carers by:
● respecting the person and their family’s knowledge and experience of
ADHD
● being sensitive to stigma in relation to mental illness.
12.1.2.2 Healthcare professionals should provide people with ADHD and their fami-
lies or carers with relevant, age-appropriate information (including written
information) about ADHD at every stage of their care. The information
should cover diagnosis and assessment, support and self-help, psychologi-
cal treatment, and the use and possible side effects of drug treatment.
12.1.2.3 When assessing a child or young person with ADHD, and throughout their
care, healthcare professionals should:
● allow the child or young person to give their own account of how they
feel, and record this in the notes
● involve the child or young person and the family or carer in treatment
decisions
● take into account expectations of treatment, so that informed consent
can be obtained from the child’s parent or carer or the young person
before treatment is started.
12.1.2.4 Healthcare professionals working with children and young people with
ADHD should be:
● familiar with local and national guidelines on confidentiality and the
rights of the child
● able to assess the young person’s understanding of issues related to
ADHD and its treatment (including Gillick competence)
● familiar with parental consent and responsibilities, child protection
issues, the Mental Health Act (2007) and the Children Act (1989).
12.1.2.5 Healthcare professionals should work with children and young people with
ADHD and their parents or carers to anticipate major life changes (such as
puberty, starting or changing schools, the birth of a sibling) and make
appropriate arrangements for adequate personal and social support during
times of increased need. The need for psychological treatment at these
times should be considered.
12.1.2.6 Adults with ADHD should be given written information about local and
national support groups and voluntary organisations.
12.1.2.7 Healthcare professionals should ask families or carers about the impact of
ADHD on themselves and other family members, and discuss any
concerns they may have. Healthcare professionals should:
● offer family members or carers an assessment of their personal, social
and mental health needs
● encourage participation in self-help and support groups where appro-
priate
Summary of recommendations
361
Summary of recommendations
362
● offer general advice to parents and carers about positive parent– and
carer–child contact, clear and appropriate rules about behaviour, and
the importance of structure in the child or young person’s day
● explain that parent-training/education programmes do not necessarily
imply bad parenting, and that their aim is to optimise parenting skills
to meet the above-average parenting needs of children and young
people with ADHD.
12.1.3 Training
12.1.3.1 Trusts should ensure that specialist ADHD teams for children, young
people and adults jointly develop age-appropriate training programmes for
the diagnosis and management of ADHD for mental health, paediatric,
social care, education, forensic and primary care providers and other
professionals who have contact with people with ADHD.
12.1.3.2 Child and adult psychiatrists, paediatricians, and other child and adult
mental health professionals (including those working in forensic services)
should undertake training so that they are able to diagnose ADHD and
provide treatment and management in accordance with this guideline.
12.1.3.3 The Department for Children, Schools and Families should consider
providing more education to trainee teachers about ADHD by working
with the Training and Development Agency for Schools (TDA) and rele-
vant health service organisations to produce training programmes and
guidance for supporting children with ADHD.
CARE PATHWAY FOR THE TREATMENT AND CARE OF PEOPLE
WITH ADHD
12.2 IDENTIFICATION, PRE-DIAGNOSTIC INTERVENTION IN THE
COMMUNITY AND REFERRAL TO SECONDARY SERVICES
12.2.1 Identification and referral in children and young people
with ADHD
12.2.1.1 Universal screening for ADHD should not be undertaken in nursery,
primary and secondary schools.
12.2.1.2 When a child or young person with disordered conduct and suspected
ADHD is referred to a school’s special educational needs coordinator
(SENCO), the SENCO, in addition to helping the child with their behaviour,
should inform the parents about local parent-training/education programmes.
12.2.1.3 Referral from the community to secondary care may involve health, educa-
tion and social care professionals (for example, GPs, paediatricians,
educational psychologists, SENCOs, social workers) and care pathways
Summary of recommendations
363
can vary locally. The person making the referral to secondary care should
inform the child or young person’s GP.
12.2.1.4 When a child or young person presents in primary care with behavioural
and/or attention problems suggestive of ADHD, primary care practitioners
should determine the severity of the problems, how these affect the child
or young person and the parents or carers and the extent to which they
pervade different domains and settings.
12.2.1.5 If the child or young person’s behavioural and/or attention problems
suggestive of ADHD are having an adverse impact on their development or
family life, healthcare professionals should consider:
● a period of watchful waiting of up to 10 weeks
● offering parents or carers a referral to a parent-training/education
programme (this should not wait for a formal diagnosis of ADHD).
If the behavioural and/or attention problems persist with at least moderate
impairment, the child or young person should be referred to secondary care
(that is, a child psychiatrist, paediatrician, or specialist ADHD CAMHS)
for assessment.
12.2.1.6 If the child or young person’s behavioural and/or attention problems are
associated with severe impairment, referral should be made directly to
secondary care (that is, a child psychiatrist, paediatrician, or specialist
ADHD CAMHS) for assessment.
12.2.1.7 Group-based parent-training/education programmes are recommended in
the management of children with conduct disorders
36
.
12.2.1.8 Primary care practitioners should not make the initial diagnosis or start
drug treatment in children or young people with suspected ADHD.
12.2.1.9 A child or young person who is currently treated in primary care with
methylphenidate, atomoxetine, dexamfetamine, or any other psychotropic
drug for a presumptive diagnosis of ADHD, but has not yet been assessed
by a specialist in ADHD in secondary care, should be referred for assess-
ment to a child psychiatrist, paediatrician, or specialist ADHD CAMHS as
a matter of clinical priority.
12.2.2 Identification and referral in adults with ADHD
12.2.2.1 Adults presenting with symptoms of ADHD in primary care or general
adult psychiatric services, who do not have a childhood diagnosis of
ADHD, should be referred for assessment by a mental health specialist
trained in the diagnosis and treatment of ADHD, where there is evidence
of typical manifestations of ADHD (hyperactivity/impulsivity and/or inat-
tention) that:
● began during childhood and have persisted throughout life
36
This recommendation is taken from TA102 (NICE, 2006a) [replaced by ‘Antisocial Behaviour and
Conduct Disorders in Children and Young People’, NICE clinical guideline 158]. See recommendation
12.5.1.4 for the extended use of these programmes to include children with ADHD.
Summary of recommendations
364
● are not explained by other psychiatric diagnoses (although there may
be other coexisting psychiatric conditions)
● have resulted in or are associated with moderate or severe psychologi-
cal, social and/or educational or occupational impairment.
12.2.2.2 Adults who have previously been treated for ADHD as children or young
people and present with symptoms suggestive of continuing ADHD should
be referred to general adult psychiatric services for assessment. The symp-
toms should be associated with at least moderate or severe psychological
and/or social or educational or occupational impairment.
12.3 DIAGNOSIS OF ADHD
12.3.1.1 A diagnosis of ADHD should only be made by a specialist psychiatrist,
paediatrician or other appropriately qualified healthcare professional with
training and expertise in the diagnosis of ADHD, on the basis of:
● a full clinical and psychosocial assessment of the person; this should
include discussion about behaviour and symptoms in the different
domains and settings of the person’s everyday life, and
● a full developmental and psychiatric history, and
● observer reports and assessment of the person’s mental state.
12.3.1.2 A diagnosis of ADHD should not be made solely on the basis of rating
scale or observational data. However rating scales such as the Conners’
rating scales and the Strengths and Difficulties questionnaire are valuable
adjuncts, and observations (for example, at school) are useful when there
is doubt about symptoms.
12.3.1.3 For a diagnosis of ADHD, symptoms of hyperactivity/impulsivity and/or
inattention should:
● meet the diagnostic criteria in DSM-IV or ICD-10 (hyperkinetic disor-
der)
37
, and
● be associated with at least moderate psychological, social and/or
educational or occupational impairment based on interview and/or
direct observation in multiple settings, and
● be pervasive, occurring in two or more important settings including
social, familial, educational and/or occupational settings.
As part of the diagnostic process, include an assessment of the person’s
needs, coexisting conditions, social, familial and educational or occupa-
tional circumstances and physical health. For children and young people,
there should also be an assessment of their parents’ or carers’ mental health.
12.3.1.4 ADHD should be considered in all age groups, with symptom criteria
adjusted for age-appropriate changes in behaviour.
37
The ICD-10 exclusion on the basis of a pervasive developmental disorder being present, or the time of
onset being uncertain, is not recommended.
Summary of recommendations
365
12.3.1.5 In determining the clinical significance of impairment resulting from the
symptoms of ADHD in children and young people, their views should be
taken into account wherever possible.
12.4 POST-DIAGNOSTIC ADVICE
12.4.1 General advice
12.4.1.1 Following a diagnosis of ADHD, healthcare professionals should consider
providing all parents or carers of all children and young people with
ADHD self-instruction manuals, and other materials such as videos, based
on positive parenting and behavioural techniques.
12.4.2 Dietary advice
12.4.2.1 Healthcare professionals should stress the value of a balanced diet, good
nutrition and regular exercise for children, young people and adults with
ADHD.
12.4.2.2 The elimination of artificial colouring and additives from the diet is not
recommended as a generally applicable treatment for children and young
people with ADHD.
12.4.2.3 Clinical assessment of ADHD in children and young people should include
asking about foods or drinks that appear to influence their hyperactive
behaviour. If there is a clear link, healthcare professionals should advise
parents or carers to keep a diary of food and drinks taken and ADHD
behaviour. If the diary supports a relationship between specific foods and
drinks and behaviour, then referral to a dietitian should be offered. Further
management (for example, specific dietary elimination) should be jointly
undertaken by the dietitian, mental health specialist or paediatrician, and
the parent or carer and child or young person.
12.4.2.4 Dietary fatty acid supplementation is not recommended for the treatment
of ADHD in children and young people.
12.5 TREATMENT FOR CHILDREN AND YOUNG PEOPLE
12.5.1 Treatment for pre-school children
12.5.1.1 Drug treatment is not recommended for pre-school children with ADHD.
12.5.1.2 Following a diagnosis of ADHD in a child of pre-school age, healthcare
professionals should, with the parents’ or carers’ consent, contact the
child’s nursery or pre-school teacher to explain:
● the diagnosis and severity of symptoms and impairment
Summary of recommendations
366
● the care plan
● any special educational needs.
12.5.1.3 Healthcare professionals should offer parents or carers of pre-school chil-
dren with ADHD a referral to a parent-training/education programme as
the first-line treatment if the parents or carers have not already attended
such a programme or the programme has had a limited effect.
12.5.1.4 Group-based parent-training/education programmes, developed for the
treatment and management of children with conduct disorders,
38
should be
fully accessible to parents or carers of children with ADHD whether or not
the child also has a formal diagnosis of conduct disorder.
12.5.1.5 Individual-based parent-training/education programmes
39
are recom-
mended in the management of children with ADHD when:
● a group programme is not possible because of low participant numbers
● there are particular difficulties for families in attending group sessions
(for example, because of disability, needs related to diversity such as
language differences, parental ill-health, problems with transport, or
where other factors suggest poor prospects for therapeutic engage-
ment)
● a family’s needs are too complex to be met by group-based parent-
training/education programmes.
12.5.1.6 When individual-based parent-training/education programmes for pre-
school children with ADHD are undertaken, the skills training stages
should involve both the parents or carers and the child.
12.5.1.7 This recommendation has been replaced by recommendations 1.5.2 and
1.5.4 in ‘Antisocial Behaviour and Conduct Disorders in Children and
Young People’ (NICE clinical guideline 158)
40
.
38
As recommended in TA102 (NICE, 2006a) [replaced by ‘Antisocial Behaviour and Conduct Disorders in
Children and Young People’, NICE clinical guideline 158].
39
Ibid.
40
This recommendation has been replaced.
12.5.1.8 Consideration should be given to involving both of the parents or all carers
of children or young people with ADHD in parent-training/education
programmes wherever this is feasible.
12.5.1.9 This recommendation has been replaced by recommendations 1.5.2 and
1.5.4 in ‘Antisocial Behaviour and Conduct Disorders in Children and
Young People’ (NICE clinical guideline 158)
41
.
12.5.1.10 This recommendation has been deleted
42
.
12.5.1.11 If overall treatment, including parent-training/education programmes, has
been effective in managing ADHD symptoms and any associated impair-
ment in pre-school children, before considering discharge from secondary
care healthcare professionals should:
● review the child, with their parents or carers and siblings, for any resid-
ual coexisting conditions and develop a treatment plan for these if
needed
● monitor for the recurrence of ADHD symptoms and any associated
impairment that may occur after the child starts school.
12.5.1.12 If overall treatment, including parent-training/education programmes, has
not been effective in managing ADHD symptoms and any associated
impairment in pre-school children, healthcare professionals should
consider referral to tertiary services for further care.
12.5.2 Treatment for school-age children and young people with ADHD
and moderate impairment
12.5.2.1 Drug treatment is not indicated as the first-line treatment for all school-age
children and young people with ADHD. It should be reserved for those
with severe symptoms and impairment or for those with moderate levels of
impairment who have refused non-drug interventions, or whose symptoms
have not responded sufficiently to parent-training/education programmes
or group psychological treatment.
12.5.2.2 Following a diagnosis of ADHD in a school-age child or young person
healthcare professionals should, with the parents’ or carers’ consent, contact
the child or young person’s teacher to explain:
● the diagnosis and severity of symptoms and impairment
● the care plan
● any special educational needs.
12.5.2.3 Teachers who have received training about ADHD and its management
should provide behavioural interventions in the classroom to help children
and young people with ADHD.
Summary of recommendations
367
41
This recommendation has been replaced.
42
This recommendation has been deleted.
Summary of recommendations
368
12.5.2.4 If the child or young person with ADHD has moderate levels of impair-
ment, the parents or carers should be offered referral to a group parent-
training/education programme, either on its own or together with a group
treatment programme (CBT and/or social skills training) for the child or
young person.
12.5.2.5 When using group treatment (CBT and/or social skills training) for the
child or young person in conjunction with a parent-training/education
programme, particular emphasis should be given to targeting a range of
areas, including social skills with peers, problem solving, self-control,
listening skills and dealing with and expressing feelings. Active learning
strategies should be used, and rewards given for achieving key elements
of learning.
12.5.2.6 For older adolescents with ADHD and moderate impairment, individual
psychological interventions (such as CBT or social skills training) may be
considered as they may be more effective and acceptable than group parent-
training/education programmes or group CBT and/or social skills training.
12.5.2.7 For children and young people (including older age groups) with ADHD
and a learning disability, a parent-training/education programme should be
offered on either a group or individual basis, whichever is preferred follow-
ing discussion with the parents or carers and the child or young person.
12.5.2.8 When parents or carers of children or young people with ADHD undertake
parent-training/education programmes, the professional delivering the
sessions should consider contacting the school and providing the child or
young person’s teacher with written information on the areas of behav-
ioural management covered in these sessions. This should only be done
with parental consent.
12.5.2.9 Following successful treatment with a parent-training/education programme
and before considering discharge from secondary care, the child or young
person should be reviewed, with their parents or carers and siblings, for any
residual problems such as anxiety, aggression or learning difficulties.
Treatment plans should be developed for any coexisting conditions.
12.5.2.10 Following treatment with a parent-training/education programme, children
and young people with ADHD and persisting significant impairment
should be offered drug treatment.
12.5.3 Treatment for school-age children and young people with severe
ADHD (hyperkinetic disorder) and severe impairment
12.5.3.1 In school-age children and young people with severe ADHD, drug treat-
ment should be offered as the first-line treatment. Parents should also be
offered a group-based parent-training/education programme.
12.5.3.2 Drug treatment should only be initiated by an appropriately qualified
healthcare professional with expertise in ADHD and should be based on a
comprehensive assessment and diagnosis. Continued prescribing and
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